Sage Program Reimbursement Rates (Effective Jan 1, 2018 through Dec 31, 2018)

Size: px

Start display at page:

Download "Sage Program Reimbursement Rates (Effective Jan 1, 2018 through Dec 31, 2018)"

Randolph Higgins
5 years ago
Views:

1 Sage Program Reimbursement Rates Code Description of Service Allowable Rates New Patient History, exam, straight forward decision-making; 10 $ Expanded history; exam, straightforward decision-making; 20 $ Detailed history, exam, straightforward decision-making; 30 $ Established Patient Evaluation and management; 5 $ Evaluation and management, problem focused history, problem focused examination straightforward medical decision-making; 10 $ Expanded history and exam straight forward decision-making; 15 $ Established Patient, detailed exam (25 ) $ G0101 Pelvic exam with breast exam $37.93 G0463 Hospital outpatient clinic visit for assessment and management of a $ patient Will be reimbursed at or below the rate Will be reimbursed at or below the rate Cervical Screening 88150, 88164, P3000 Conventional Screening Pap $ , G0123 Liquid-based, thin layer prep Screening Pap $ Liquid-based, thin layer prep Screening Pap, manual screening and rescreening under physician supervision. $ , G0144 Liquid-based, thin layer prep Screening Pap, screening by automated system. $ , G0145 Liquid-based, thin layer prep Screening Pap, screening by automated system and manual rescreening. $32.71 Pap Smear/Pathology with Additional Interpretation 88141, G0124 Cytopathology, cervical / vaginal; requiring physician interpretation $32.82 P3001 Screening Pap Smear, requiring interpretation by physician $32.82 HPV Test Human Papillomavirus (HPV) Test high-risk types $ Human Papillomavirus (HPV) Test types 16 & 18 only $43.33 Colposcopy Colposcopy of entire vagina, with cervix if present-without Biopsy (this CPT code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy) Colposcopy of entire vagina, with cervix if present-with Biopsy(s) (this CPT code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy) $ $ Colposcopy - Without Cervical Biopsy $107.09

2 Sage Program Reimbursement Rates Code Description of Service Allowable Rates Colposcopy - With Cervical Biopsy(s) and Endocervical Curettage $ Colposcopy - With Cervical Biopsy(s) $ Colposcopy - With Endocervical Curettage $ Endometrial Biopsy Endometrial Biopsy $ Endometrial Biopsy performed in conjunction with Colposcopy $47.17 Pathology Global TC Surgical Cervical Pathology, Global $69.92 $30.34 $39.58 Mammography Global TC Screening Mammogram w/cad Bilateral $ $ $ Diagnostic Mammogram w/cad Bilateral $ $ $ Diagnostics Mammogram w/cad Unilateral $ $96.94 $39.22 Tomosynthesis/ 3d Mammogram Global TC Screening digital breast Tomosynthesis $55.80 $25.84 $29.95 G0279 Diagnostic digital breast, Tomosynthesis $55.80 $25.84 $29.95 Breast Ultrasound Global TC Ultrasound breast complete, Unilateral $ $73.29 $ Ultrasound breast limited, Unilateral $89.87 $55.82 $34.05 Fine Needle Aspiration Allowable Rates Fine Needle Aspiration (without imaging guidance) $ Fine Needle Aspiration (with imaging guidance) $ Aspiration of Cyst $ Cytology Global TC Evaluation of Fine Needle Aspirate $58.66 $20.88 $ Interpretation and Report $ $74.34 $73.61 Outpatient Breast Diagnostic Procedures (special arrangements must be made with SAGE prior to offering these services) Itemized charges for each procedure code Patient Breast Diagnostic Procedures (must receive prior authorization for each procedure). Please call for instructions. * Sage rates are based on CMS rates and subject to adjustment whenever CMS does the same. TC: Technical Component 26: Professional Component Varies

3 Sage Program Breast Diagnostic Reimbursement Rates Code Description of Service Visit Allowable Rates History, exam, straight forward decision-making; 10 $ Expanded history; exam, straightforward decision-making; 20 $ Detailed history, exam, straightforward decision-making; 30 $ Comprehensive history, exam, moderate complexity decision-making; 45 $ Comprehensive history, exam, high complexity decision-making; 60 $ Evaluation and management; 5 $ Evaluation and management, problem focused history, problem focused examination straightforward medical decision-making; 10. $ Expanded history and exam straight forward decision-making; 15 $ Established Patient, detailed exam (25 ) $ G0463 Hospital outpatient clinic visit for assessment and management of a $ patient Will be reimbursed at or below the rate Will be reimbursed at or below the rate Diagnostic Mammography Global Tech Prof Diagnostic Mammogram w/cad Bilateral. $ $ $ Diagnostics Mammogram w/cad Unilateral. $ $96.94 $39.22 Breast Ultrasound Global Tech Prof Ultrasound breast complete, Unilateral $ $73.29 $ Ultrasound breast limited, Unilateral $89.87 $55.82 $ Ultrasonic guidance for needle placement, imaging supervision and interpretation $60.62 $28.15 $32.47 Breast Diagnostic Procedures PFS (11) PFS (22) OPPS(13) Fine needle aspiration without imaging guidance $ $67.86 $ Fine needle aspiration with imaging guidance $ $64.79 $ Puncture aspiration of cyst of breast $ $42.90 $ Puncture aspiration of cyst of breast, each additional cyst, used with $26.66 $21.20 Bundled Breast biopsy, with placement of localization devise and imaging biopsy specimen, percutaneous; stereotactic guidance; first lesion $ $ $ Code plus each additional lesion $ $83.96 Bundled Breast biopsy, with placement of localization devise and imaging of biopsy specimen, percutaneous; ultrasound guidance; first lesion $ $ $ Code plus each additional lesion $ $78.52 Bundled Breast biopsy, with placement of localization devise and imaging of biopsy specimen, percutaneous, magnetic resonance guidance; first lesion $ $ $ Code plus each additional lesion $ $92.22 Bundled Breast biopsy, percutaneous, needle core, not using imaging guidance $ $66.15 $ Breast biopsy, open, incisional $ $ $ Breast biopsy, open, incisional $ $ $ Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion $ $ $ Code plus each additional lesion separately identified by a preoperative radiological marker $ $ Bundled

4 Sage Program Breast Diagnostic Reimbursement Rates Code Description of Service Placement of breast localization device, percutaneous; mammographic guidance; first lesion $ $ $ Code plus each additional lesion $ $50.57 Bundled Placement of breast localization device, percutaneous; stereotactic $ $ guidance; first lesion $ Code plus each additional lesion $ $50.72 Bundled Placement of breast localization device, percutaneous; ultrasound $ $86.22 guidance; first lesion $ Code plus each additional lesion $ $42.99 Bundled Placement of breast localization device, percutaneous; magnetic $ $ resonance guidance; first lesion $ Code plus each additional lesion $ $64.89 Bundled Anesthesia Formula Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified. Base (B): 3 units [B+(Times/15min)] *$21.33* X% Cytology & Pathology Global Tech Prof Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) $58.66 $20.88 $ Cytopathology, evaluation of fine needle aspirate; interpretation and report $ $73.61 $ Surgical pathology, gross and microscopic examination $69.92 $30.34 $ Surgical pathology, gross and microscopic examination; requiring microscopic evaluation of surgical margins $ $ $ Morphometric analysis, tumor immunohistochemistry, per specimen; manual $ $90.39 $ Morphometric analysis, tumor immunohistochemistry, per specimen; using computer-assisted technology $ $99.49 $49.31 Supplies Rate Various Pre-operative testing; complete blood count, urinalysis, pregnancy test, or other procedures medically necessary for the planned surgical procedure. Please call for instructions and or prior authorization for each procedures. Anesthesia (x) percentages by Modifier: AA Anesthesia personally provided by a physician 100% QZ Anesthesia personally provided by CRNA 100% AD Anesthesia supervised by a physician 100% QY Medical direction of Anesthesia services by a physician 50% QK Medical direction of multiple Anesthesia services by a physician 50% QX Anesthesia services provided by a CRNA under medical direction by a physician 50% * Sage rates are based on CMS rates and subject to adjustment whenever CMS does the same Tech (TC): Technical Component Prof (26): Professional Component

5 Sage Scopes Program Reimbursement Rates Code Description of Service Rates Visits PFS (11) PFS (22) OPPS (13) ASC History, exam, straight forward decision-making; 10 $44.47 $26.27 Bundled $ Expanded history; exam, straightforward decision-making; 20 $74.85 $49.74 Bundled $ Detailed history, exam, straightforward decision-making; 30 $ $74.81 Bundled $ Evaluation and management; 5 $21.88 $9.14 Bundled $ Evaluation and management, problem-focused history; 10. $43.97 $25.05 Bundled $ Expanded history and exam straight forward decision-making; 15 $72.89 $50.68 Bundled $50.68 G0463 Hospital outpatient clinic visit for assessment and management of a patient $ Will be reimbursed at or below the rate Will be reimbursed at or below the rate Moderate Sedation Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that G0500 sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and $59.90 $5.31 Bundled Bundled physiological status; initial 15 of intra-service time; patient age 5 years or older Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic services $52.32 $12.28 Bundled Bundled that the sedation supports; initial each additional 15 listed separately, in addition to the primary code $11.05 $11.05 Bundled Bundled Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the $73.97 $73.97 Bundled Bundled sedation supports; initial 15 of intraservice time, patient age 5 years or older each additional 15 listed separately, in addition to the primary code $56.53 $56.53 Bundled Bundled Prep Kit PFS OPPS ASC Supplies and materials provided by the physician $28.99 $28.99 $28.99 Colorectal Cancer Screening and Diagnostics Procedures G0121 Screening colonoscopy on average risk individual $ $ $ Colonoscopy, flexible; diagnostic including collection of specimens(s) by brushing or washing, when performed. $ $ $ Colonoscopy, flexible; with biopsy, single or multiple. $ $ $ Colonoscopy, flexible; with directed submucosal injection(s) any substance. $ $ $ Colonoscopy, flexible; with control of bleeding, any method. $ $ $ Colonoscopy, flexible; with removal of tumors, polyps(s) or other lesions(s) by hot biopsy forceps. $ $ $ Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $ $ $ Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (included preand post-dilation and guide wire passage when performed) $ $ $ Colonoscopy, flexible, with endoscopic mucosal resection. $ $ $ G0105 Will be reimbursed at or below the G0121 rate. Fecal test Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening $4.38 $4.38 $ Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations (Fecal Immunochemical Test) $19.64 $19.64 $19.64 Pathology Global Tech. Prof Surgical Pathology, gross examination only (surgical specimen) $17.47 $12.14 $ Surgical Pathology, gross and microscopic examination (review level II) $31.50 $24.15 $7.35

Sage Scopes Program Reimbursement Rates 88304 Surgical pathology, gross and microscopic examination (review level III) $41.65 $29.61 $12.

6 Sage Scopes Program Reimbursement Rates Surgical pathology, gross and microscopic examination (review level III) $41.65 $29.61 $ Surgical pathology, gross and microscopic examination, colon, colorectal polyp biopsy (review level IV) $69.92 $30.24 $ Surgical Pathology, gross and microscopic examination (review level III) $ $ $ Surgical pathology, gross and microscopic examination, colon, segmental resection for tumor or total resection (review level VI) $ $ $ Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure $ $74.74 $ Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) $95.22 $65.51 $29.71 Anesthesiology Formula Anesthesia for lower intestinal endoscopy procedures, endoscope introduced distal to duodenum; not otherwise specified. Base (B): 4 units Anesthesia for lower intestinal endoscopy procedures, endoscope introduced distal to duodenum; screening colonoscopy. Base (B): 3 units [B+(Times/15min)] *$21.33* X% Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified. Base (B): 6 units Electrocardiogram Rate Routine ECG with at least 12 leads; with interpretation and report $ Routine ECG with at least 12 leads; tracing only, without interpretation and report $ Routine ECG with at least 12 leads; tracing only interpretation and report $ Rhythm ECG, one to three leads; with interpretation and report $ Rhythm ECG, one to three leads; tracing only without interpretation and report $ Rhythm ECG, one to leads; interpretation and report only $6.98 Lab Work Basic metabolic panel (calcium, total). This panel must include the following: calcium, total (82310), carbon dioxide (82374), creatinine (82565), glucose (82947), potassium (84132) $10.44 and sodium (84295) Comprehensive metabolic panel. This panel must include the following: albumin (82040), bilirubin total (82247), calcium (82310), carbon dioxide bicarbonate (82374), chloride (82435), creatinine (82565), glucose (82947), phosphatase alkaline (84075), potassium $13.04 (84132), total protein (84155), sodium (84295), transferase alanine amino (84460), transferase aspartate amino (84450), and urea nitrogen (84520) Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count $ Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) $ Prothrombin time $ Thromboplastin time, partial (PTT); plasma, or whole blood $7.42 Anesthesia (x) percentages by Modifier: AA Anesthesia personally provided by a physician 100% QZ Anesthesia personally provided by CRNA 100% AD Anesthesia supervised by a physician 100% QY Medical direction of Anesthesia services by a physician 50% QK Medical direction of multiple Anesthesia services by a physician 50% QX Anesthesia services provided by a CRNA under medical direction by a physician 50% * Sage Scopes rates are based on CMS rates and subject to adjustment whenever CMS does the same

FY 2017 MCRCEDP Procedure Code Reference Chart

FY 2017 MCRCEDP Procedure Code Reference Chart 45378-53 45380 45381 45382 45384 45385 48388 45390 ; Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon